﻿<?xml version="1.0" encoding="utf-8" ?>
<TransactionSpecification xmlns="http://tempuri.org/X12ParserSpecification.xsd" TransactionSetIdentifierCode="837">
  <Segment SegmentId="BHT" Usage="Required" Repeat="1"/>
  <Segment SegmentId="REF" Usage="Required" Repeat="1"/>
  <Loop LoopId="1000A" Usage="Required" LoopRepeat="1">
    <Name>SUBMITTER NAME</Name>
    <StartingSegment SegmentId="NM1" Usage="Required" Repeat="1">
      <EntityIdentifier Code="41"/>
    </StartingSegment>
    <Segment SegmentId="PER" Usage="Required" Repeat="2"/>
  </Loop>
  <Loop LoopId="1000B" Usage="Required" LoopRepeat="1">
    <Name>RECEIVER NAME</Name>
    <StartingSegment SegmentId="NM1" Usage="Required" Repeat="1">
      <EntityIdentifier Code="40"/>
    </StartingSegment>
    <Segment SegmentId="PER" Usage="Required" Repeat="2"/>
  </Loop>
  <HierarchicalLoop LoopId="2000A" Usage="Required" LevelCode="20">
    <Name>BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL</Name>
    <Segment SegmentId="PRV" Usage="Required" Repeat="1"/>
    <Segment SegmentId="CUR" Usage="Situational" Repeat="1"/>
    <Loop LoopId="2010AA" Usage="Required" LoopRepeat="1">
      <Name>BILLING PROVIDER NAME</Name>
      <StartingSegment SegmentId="NM1" Usage="Required" Repeat="1">
        <EntityIdentifier Code="85"/>
      </StartingSegment>
      <Segment SegmentId="N3" Usage="Required" Repeat="1"/>
      <Segment SegmentId="N4" Usage="Required" Repeat="1"/>
      <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
      <Segment SegmentId="PER" Usage="Situational" Repeat="8"/>
      <Segment SegmentId="PRV" Usage="Required" Repeat="1"/>
    </Loop>
    <Loop LoopId="2010AB" Usage="Situational" LoopRepeat="1">
      <Name>PAY-TO PROVIDER'S NAME</Name>
      <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
        <EntityIdentifier Code="87"/>
      </StartingSegment>
      <Segment SegmentId="N3" Usage="Required" Repeat="1"/>
      <Segment SegmentId="N4" Usage="Required" Repeat="1"/>
      <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
      <Segment SegmentId="PRV" Usage="Required" Repeat="1"/>
    </Loop>
  </HierarchicalLoop>
  <HierarchicalLoop LoopId="2000B" Usage="Required" LevelCode="22">
    <Name>SUBSCRIBER HIERARCHICAL LOOP</Name>
    <Segment SegmentId="SBR" Usage="Required" Repeat="1"/>
    <Segment SegmentId="PAT" Usage="Situational" Repeat="1"/>
    <Loop LoopId="2010BA" Usage="Required" LoopRepeat="1">
      <Name>SUBSCRIBER NAME</Name>
      <StartingSegment SegmentId="NM1" Usage="Required" Repeat="1">
        <EntityIdentifier Code="IL"/>
      </StartingSegment>
      <Segment SegmentId="N3" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="N4" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="DMG" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="REF" Usage="Situational" Repeat="4"/>
      <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
    </Loop>
    <Loop LoopId="2010BB" Usage="Situational" LoopRepeat="1">
      <Name>PAYER NAME</Name>
      <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
        <EntityIdentifier Code="PR"/>
        <EntityIdentifier Code="IN"/> <!-- For Property & Casualty Claim -->
      </StartingSegment>
      <Segment SegmentId="N3"/>
      <Segment SegmentId="N4"/>
      <Segment SegmentId="REF" Usage="Situational" Repeat="3"/>
    </Loop>
    <Loop LoopId="2010BC" Usage="Required" LoopRepeat="1">
      <Name>RESPONSIBLE PARTY NAME</Name>
      <StartingSegment SegmentId="NM1" Usage="Required" Repeat="1">
        <EntityIdentifier Code="QD"/>
      </StartingSegment>
      <Segment SegmentId="N3" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="N4" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="DMG" Usage="Situational" Repeat="1"/>
    </Loop>
    <Loop LoopId="2010BD" Usage="Situational" LoopRepeat="1">
      <Name>CREDIT/DEBIT CARD HOLDER NAME NAME</Name>
      <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
        <EntityIdentifier Code="AO"/>
      </StartingSegment>
      <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
    </Loop>
    <Loop LoopId="2010" Usage="Situational" LoopRepeat="1">
      <Name>Generic X12 2010 Loop</Name>
      <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
        <EntityIdentifier Code="84"/>
      </StartingSegment>
      <Segment SegmentId="N3" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="N4" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="DMG" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="PER" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="UI" Usage="Situational" Repeat="1"/>
    </Loop>
    <Loop LoopId="2300" Usage="Required" LoopRepeat="100">
      <Name>CLAIM INFORMATION</Name>
      <StartingSegment SegmentId="CLM" Usage="Required" Repeat="1"/>
      <!--Professional Segments-->
      <Segment SegmentId="DTP" Usage="Situational" Repeat="10"/>
      <Segment SegmentId="PWK" Usage="Situational" Repeat="10"/>
      <Segment SegmentId="CN1" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="AMT" Usage="Situational" Repeat="2"/>
      <Segment SegmentId="REF" Usage="Situational" Repeat="10"/>
      <Segment SegmentId="K3" Usage="Situational" Repeat="10"/>
      <Segment SegmentId="NTE" Usage="Situational" Repeat="20"/>
      <Segment SegmentId="CR1" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="CR2" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="CRC" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="HI" Usage="Situational" Repeat="17"/>
      <Segment SegmentId="HCP" Usage="Situational" Repeat="1"/>
      <!--Dental Specific Segments-->
      <Segment SegmentId="DN1" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="DN2" Usage="Situational" Repeat="35"/>
      <!--Institutional Specific Segments-->
      <Segment SegmentId="CL1" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="QTY" Usage="Situational" Repeat="4"/>
      <Loop LoopId="2305" Usage="Situational" LoopRepeat="6">
        <Name>HOME HEALTH CARE PLAN INFORMATION</Name>
        <StartingSegment SegmentId="CR7" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="HSD" Usage="Situational" Repeat="1"/>
      </Loop>
      <Loop LoopId="2310A" Usage="Situational" LoopRepeat="2">
        <Name>REFERRING PROVIDER NAME</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="DN"/>
          <EntityIdentifier Code="P3"/>
        </StartingSegment>
        <Segment SegmentId="PRV" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
      </Loop>
      <Loop LoopId="2310B" Usage="Situational" LoopRepeat="1">
        <Name>RENDERING PROVIDER NAME</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="82"/>
        </StartingSegment>
        <Segment SegmentId="PRV" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
      </Loop>
      <Loop LoopId="2310C" Usage="Situational" LoopRepeat="1">
        <Name>PURCHASED SERVICE PROVIDER NAME</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="QB"/>
        </StartingSegment>
        <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
      </Loop>
      <Loop LoopId="2310D" Usage="Situational" LoopRepeat="1">
        <Name>SERVICE FACILITY LOCATION</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="77"/>
          <EntityIdentifier Code="FA"/>
          <EntityIdentifier Code="LI"/>
          <EntityIdentifier Code="TL"/>
        </StartingSegment>
        <Segment SegmentId="N3" Usage="Required" Repeat="1"/>
        <Segment SegmentId="N4" Usage="Required" Repeat="1"/>
        <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
      </Loop>
      <Loop LoopId="2310E" Usage="Situational" LoopRepeat="1">
        <Name>SUPERVISING PROVIDER NAME</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="DQ"/>
        </StartingSegment>
        <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
      </Loop>

      <Loop LoopId="2320" Usage="Situational" LoopRepeat="10">
        <Name>OTHER SUBSCRIBER INFORMATION</Name>
        <StartingSegment SegmentId="SBR" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="CAS" Usage="Situational" Repeat="5"/>
        <Segment SegmentId="AMT" Usage="Situational" Repeat="7"/>
        <Segment SegmentId="DMG" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="OI" Usage="Required" Repeat="1"/>
        <Segment SegmentId="MOA" Usage="Situational" Repeat="1"/>
        <!-- Institutional Specific Segments-->
        <Segment SegmentId="MIA" Usage="Situational" Repeat="1"/>
        <Loop LoopId="2330A" Usage="Required" LoopRepeat="1">
          <Name>OTHER SUBSCRIBER NAME</Name>
          <StartingSegment SegmentId="NM1" Usage="Required" Repeat="1">
            <EntityIdentifier Code="IL"/>
          </StartingSegment>
          <Segment SegmentId="N3" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="N4" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="REF" Usage="Situational" Repeat="3"/>
          <Segment SegmentId="DMG"/>
        </Loop>
        <Loop LoopId="2330B" Usage="Situational" LoopRepeat="1">
          <Name>OTHER SUBSCRIBER/PAYER NAME</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="PR"/>
            <EntityIdentifier Code="IN"/>
            <!-- For Property & Casualty Claim -->
          </StartingSegment>
          <Segment SegmentId="N3" Usage="Situational"/>
          <Segment SegmentId="N4" Usage="Situational"/>
          <Segment SegmentId="PER" Usage="Situational" Repeat="2"/>
          <Segment SegmentId="DTP" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="REF" Usage="Situational" Repeat="3"/>
        </Loop>
        <Loop LoopId="2330C" Usage="Situational" LoopRepeat="1">
          <Name>OTHER PAYER PATIENT INFORMATION</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="QC"/>
          </StartingSegment>
          <Segment SegmentId="REF" Usage="Situational" Repeat="3"/>
        </Loop>
        <Loop LoopId="2330D" Usage="Situational" LoopRepeat="1">
          <Name>OTHER PAYER REFERRING PROVIDER</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="DN"/>
            <EntityIdentifier Code="P3"/>
          </StartingSegment>
          <Segment SegmentId="REF" Usage="Situational" Repeat="3"/>
        </Loop>
        <Loop LoopId="2330E" Usage="Situational" LoopRepeat="1">
          <Name>OTHER PAYER RENDERING PROVIDER</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="82"/>
          </StartingSegment>
          <Segment SegmentId="REF" Usage="Situational" Repeat="3"/>
        </Loop>
        <Loop LoopId="2330F" Usage="Situational" LoopRepeat="1">
          <Name>OTHER PAYER PURCHASED CARE PROVIDER PROVIDER</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="QB"/>
          </StartingSegment>
          <Segment SegmentId="REF" Usage="Situational" Repeat="3"/>
        </Loop>
        <Loop LoopId="2330G" Usage="Situational" LoopRepeat="1">
          <Name>OTHER PAYER SERVICE FACILITY LOCATION</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="77"/>
            <EntityIdentifier Code="FA"/>
            <EntityIdentifier Code="LI"/>
            <EntityIdentifier Code="TL"/>
          </StartingSegment>
          <Segment SegmentId="N3" />
          <Segment SegmentId="N4" />
          <Segment SegmentId="REF" Usage="Required" Repeat="1"/>
        </Loop>
      </Loop>
      <Loop LoopId="2330H" Usage="Situational" LoopRepeat="1">
        <Name>OTHER PAYER SUPERVISING PROVIDER</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="DQ"/>
        </StartingSegment>
        <Segment SegmentId="REF" Usage="Situational" Repeat="3"/>
      </Loop>
      <!--Institutional Loops Begin-->
      <Loop LoopId="2310A" Usage="Situational" LoopRepeat="2">
        <Name>ATTENDING PHYSICIAN NAME</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="71"/>
        </StartingSegment>
        <Segment SegmentId="PRV" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
      </Loop>
      <Loop LoopId="2310B" Usage="Situational" LoopRepeat="2">
        <Name>OPERATING PHYSICIAN NAME</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="72"/>
        </StartingSegment>
        <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
      </Loop>
      <Loop LoopId="2310C" Usage="Situational" LoopRepeat="2">
        <Name>OTHER PROVIDER NAME</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="73"/>
        </StartingSegment>
        <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
      </Loop>
      <!--Institutional Loops End-->
      <Loop LoopId="2400" Usage="Required" LoopRepeat="50">
        <Name>SERVICE LINE</Name>
        <StartingSegment SegmentId="LX" Usage="Required" Repeat="1"/>
        <Segment SegmentId="SV1" Usage="Required" Repeat="1"/>
        <Segment SegmentId="SV5" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="PWK" Usage="Required" Repeat="5"/>
        <Segment SegmentId="CR1" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="CR2" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="CR3" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="CR5" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="CRC" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="DTP" Usage="Situational" Repeat="35"/>
        <Segment SegmentId="MEA" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="CN1" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="REF" Usage="Situational" Repeat="4"/>
        <Segment SegmentId="AMT" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="K3" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="NTE" Usage="Situational" Repeat="10"/>
        <Segment SegmentId="PS1" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="HSD" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="HCP" Usage="Situational" Repeat="1"/>
        <!-- Institutional Specific Segments-->
        <Segment SegmentId="SV2" Usage="Required" Repeat="1"/>
        <Segment SegmentId="QTY" Usage="Situational" Repeat="5"/>
        <!-- Dental Specific Segments-->
        <Segment SegmentId="SV3" Usage="Required" Repeat="1"/>
        <Segment SegmentId="TOO" Usage="Required" Repeat="25"/>
        <Loop LoopId="2410" Usage="Situational" LoopRepeat="25">
          <Name>DRUG IDENTIFICATION</Name>
          <StartingSegment SegmentId="LIN" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="CTP" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
        </Loop>
        <Loop LoopId="2420A" Usage="Situational" LoopRepeat="1">
          <Name>RENDERING PROVIDER NAME</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="82"/>
          </StartingSegment>
          <Segment SegmentId="PRV" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
        </Loop>
        <Loop LoopId="2420B" Usage="Situational" LoopRepeat="1">
          <Name>PURCHASED SERVICE PROVIDER</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="QB"/>
          </StartingSegment>
          <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
        </Loop>
        <Loop LoopId="2420C" Usage="Situational" LoopRepeat="1">
          <Name>SERVICE FACILITY LOCATION</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="77"/>
            <EntityIdentifier Code="FA"/>
            <EntityIdentifier Code="LI"/>
            <EntityIdentifier Code="TL"/>
          </StartingSegment>
          <Segment SegmentId="N3" Usage="Required" Repeat="1"/>
          <Segment SegmentId="N4" Usage="Required" Repeat="1"/>
          <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
        </Loop>
        <Loop LoopId="2420D" Usage="Situational" LoopRepeat="1">
          <Name>SUPERVISING PROVIDER NAME</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="DQ"/>
          </StartingSegment>
          <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
        </Loop>
        <Loop LoopId="2420E" Usage="Situational" LoopRepeat="1">
          <Name>ORDERING PROVIDER NAME</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="DK"/>
          </StartingSegment>
          <Segment SegmentId="N3" Usage="Required" Repeat="1"/>
          <Segment SegmentId="N4" Usage="Required" Repeat="1"/>
          <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
          <Segment SegmentId="PER" Usage="Situational" Repeat="5"/>
        </Loop>
        <Loop LoopId="2420F" Usage="Situational" LoopRepeat="1">
          <Name>REFERRING PROVIDER NAME</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="DN"/>
            <EntityIdentifier Code="P3"/>
          </StartingSegment>
          <Segment SegmentId="PRV" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
        </Loop>
        <Loop LoopId="2420G" Usage="Situational" LoopRepeat="1">
          <Name>OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="PR"/>
          </StartingSegment>
          <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
        </Loop>
        <Loop LoopId="2430" Usage="Situational" LoopRepeat="25">
          <Name>Service Line Adjudication Information</Name>
          <StartingSegment SegmentId="SVD" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="CAS" Usage="Situational" Repeat="99"/>
          <Segment SegmentId="DTP" Usage="Situational" Repeat="1"/>
        </Loop>
        <Loop LoopId="2440" Usage="Situational" LoopRepeat="5">
          <Name>FORM IDENTIFICATION CODE</Name>
          <StartingSegment SegmentId="LQ" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="FRM" Usage="Required" Repeat="99"/>
        </Loop>
      </Loop>
    </Loop>
  </HierarchicalLoop>
  <HierarchicalLoop LoopId="2000C" Usage="Situational" LevelCode="23">
    <Name>PATIENT HIERARCHICAL LOOP</Name>
    <Segment SegmentId="PAT" Usage="Required" Repeat="1"/>
    <Loop LoopId="2010CA" Usage="Required" LoopRepeat="1">
      <Name>PATIENT NAME</Name>
      <StartingSegment SegmentId="NM1" Usage="Required" Repeat="1">
        <EntityIdentifier Code="QC"/>
      </StartingSegment>
      <Segment SegmentId="N3" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="N4" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="DMG" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="REF" Usage="Situational" Repeat="4"/>
      <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
    </Loop>
    <Loop LoopId="2300" Usage="Required" LoopRepeat="100">
      <Name>CLAIM INFORMATION</Name>
      <StartingSegment SegmentId="CLM" Usage="Required" Repeat="1"/>
      <!--Professional Segments-->
      <Segment SegmentId="DTP" Usage="Situational" Repeat="10"/>
      <Segment SegmentId="PWK" Usage="Situational" Repeat="10"/>
      <Segment SegmentId="CN1" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="AMT" Usage="Situational" Repeat="2"/>
      <Segment SegmentId="REF" Usage="Situational" Repeat="10"/>
      <Segment SegmentId="K3" Usage="Situational" Repeat="10"/>
      <Segment SegmentId="NTE" Usage="Situational" Repeat="20"/>
      <Segment SegmentId="CR1" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="CR2" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="CRC" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="HI" Usage="Situational" Repeat="17"/>
      <Segment SegmentId="HCP" Usage="Situational" Repeat="1"/>
      <!--Dental Specific Segments-->
      <Segment SegmentId="DN1" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="DN2" Usage="Situational" Repeat="35"/>
      <!--Institutional Specific Segments-->
      <Segment SegmentId="CR6" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="CL1" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="QTY" Usage="Situational" Repeat="4"/>
      <Loop LoopId="2305" Usage="Situational" LoopRepeat="6">
        <Name>HOME HEALTH CARE PLAN INFORMATION</Name>
        <StartingSegment SegmentId="CR7" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="HSD" Usage="Situational" Repeat="1"/>
      </Loop>
      <Loop LoopId="2310A" Usage="Situational" LoopRepeat="2">
        <Name>REFERRING PROVIDER NAME</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="DN"/>
          <EntityIdentifier Code="P3"/>
        </StartingSegment>
        <Segment SegmentId="PRV" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
      </Loop>
      <Loop LoopId="2310B" Usage="Situational" LoopRepeat="1">
        <Name>RENDERING PROVIDER NAME</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="82"/>
        </StartingSegment>
        <Segment SegmentId="PRV" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
      </Loop>
      <Loop LoopId="2310C" Usage="Situational" LoopRepeat="1">
        <Name>PURCHASED SERVICE PROVIDER NAME</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="QB"/>
        </StartingSegment>
        <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
      </Loop>
      <Loop LoopId="2310D" Usage="Situational" LoopRepeat="1">
        <Name>SERVICE FACILITY LOCATION</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="77"/>
          <EntityIdentifier Code="FA"/>
          <EntityIdentifier Code="LI"/>
          <EntityIdentifier Code="TL"/>
        </StartingSegment>
        <Segment SegmentId="N3" Usage="Required" Repeat="1"/>
        <Segment SegmentId="N4" Usage="Required" Repeat="1"/>
        <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
      </Loop>
      <Loop LoopId="2310E" Usage="Situational" LoopRepeat="1">
        <Name>SUPERVISING PROVIDER NAME</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="DQ"/>
        </StartingSegment>
        <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
      </Loop>

      <Loop LoopId="2320" Usage="Situational" LoopRepeat="10">
        <Name>OTHER SUBSCRIBER INFORMATION</Name>
        <StartingSegment SegmentId="SBR" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="CAS" Usage="Situational" Repeat="5"/>
        <Segment SegmentId="AMT" Usage="Situational" Repeat="7"/>
        <Segment SegmentId="DMG" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="OI" Usage="Required" Repeat="1"/>
        <Segment SegmentId="MOA" Usage="Situational" Repeat="1"/>
        <!-- Institutional Specific Segments-->
        <Segment SegmentId="MIA" Usage="Situational" Repeat="1"/>
        <Loop LoopId="2330A" Usage="Required" LoopRepeat="1">
          <Name>OTHER SUBSCRIBER NAME</Name>
          <StartingSegment SegmentId="NM1" Usage="Required" Repeat="1">
            <EntityIdentifier Code="IL"/>
          </StartingSegment>
          <Segment SegmentId="N3" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="N4" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="REF" Usage="Situational" Repeat="3"/>
          <Segment SegmentId="DMG"/>
        </Loop>
        <Loop LoopId="2330B" Usage="Situational" LoopRepeat="1">
          <Name>OTHER SUBSCRIBER/PAYER NAME</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="PR"/>
            <EntityIdentifier Code="IN"/>
            <!-- For Property & Casualty Claim -->
          </StartingSegment>
          <Segment SegmentId="PER" Usage="Situational" Repeat="2"/>
          <Segment SegmentId="DTP" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="REF" Usage="Situational" Repeat="3"/>
        </Loop>
        <Loop LoopId="2330C" Usage="Situational" LoopRepeat="1">
          <Name>OTHER PAYER PATIENT INFORMATION</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="QC"/>
          </StartingSegment>
          <Segment SegmentId="REF" Usage="Situational" Repeat="3"/>
        </Loop>
        <Loop LoopId="2330D" Usage="Situational" LoopRepeat="1">
          <Name>OTHER PAYER REFERRING PROVIDER</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="DN"/>
            <EntityIdentifier Code="P3"/>
          </StartingSegment>
          <Segment SegmentId="REF" Usage="Situational" Repeat="3"/>
        </Loop>
        <Loop LoopId="2330E" Usage="Situational" LoopRepeat="1">
          <Name>OTHER PAYER RENDERING PROVIDER</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="82"/>
          </StartingSegment>
          <Segment SegmentId="REF" Usage="Situational" Repeat="3"/>
        </Loop>
        <Loop LoopId="2330F" Usage="Situational" LoopRepeat="1">
          <Name>OTHER PAYER PURCHASED CARE PROVIDER PROVIDER</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="QB"/>
          </StartingSegment>
          <Segment SegmentId="REF" Usage="Situational" Repeat="3"/>
        </Loop>
        <Loop LoopId="2330G" Usage="Situational" LoopRepeat="1">
          <Name>OTHER PAYER SERVICE FACILITY LOCATION</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="77"/>
            <EntityIdentifier Code="FA"/>
            <EntityIdentifier Code="LI"/>
            <EntityIdentifier Code="TL"/>
          </StartingSegment>
          <Segment SegmentId="N3" />
          <Segment SegmentId="N4" />
          <Segment SegmentId="REF" Usage="Required" Repeat="1"/>
        </Loop>
      </Loop>
      <Loop LoopId="2330H" Usage="Situational" LoopRepeat="1">
        <Name>OTHER PAYER SUPERVISING PROVIDER</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="DQ"/>
        </StartingSegment>
        <Segment SegmentId="REF" Usage="Situational" Repeat="3"/>
      </Loop>
      <!--Institutional Loops Begin-->
      <Loop LoopId="2310A" Usage="Situational" LoopRepeat="2">
        <Name>ATTENDING PHYSICIAN NAME</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="71"/>
        </StartingSegment>
        <Segment SegmentId="PRV" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
      </Loop>
      <Loop LoopId="2310B" Usage="Situational" LoopRepeat="2">
        <Name>OPERATING PHYSICIAN NAME</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="72"/>
        </StartingSegment>
        <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
      </Loop>
      <Loop LoopId="2310C" Usage="Situational" LoopRepeat="2">
        <Name>OTHER PROVIDER NAME</Name>
        <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
          <EntityIdentifier Code="73"/>
        </StartingSegment>
        <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
      </Loop>
      <!--Institutional Loops End-->
      <Loop LoopId="2400" Usage="Required" LoopRepeat="50">
        <Name>SERVICE LINE</Name>
        <StartingSegment SegmentId="LX" Usage="Required" Repeat="1"/>
        <Segment SegmentId="SV1" Usage="Required" Repeat="1"/>
        <Segment SegmentId="SV5" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="PWK" Usage="Required" Repeat="5"/>
        <Segment SegmentId="CR1" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="CR2" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="CR3" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="CR5" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="CRC" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="DTP" Usage="Situational" Repeat="35"/>
        <Segment SegmentId="MEA" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="CN1" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="REF" Usage="Situational" Repeat="4"/>
        <Segment SegmentId="AMT" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="K3" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="NTE" Usage="Situational" Repeat="10"/>
        <Segment SegmentId="PS1" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="HSD" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="HCP" Usage="Situational" Repeat="1"/>
        <!-- Institutional Specific Segments-->
        <Segment SegmentId="CR6" Usage="Situational" Repeat="1"/>
        <Segment SegmentId="SV2" Usage="Required" Repeat="1"/>
        <Segment SegmentId="QTY" Usage="Situational" Repeat="5"/>
        <!-- Dental Specific Segments-->
        <Segment SegmentId="SV3" Usage="Required" Repeat="1"/>
        <Segment SegmentId="TOO" Usage="Required" Repeat="25"/>
        <Loop LoopId="2410" Usage="Situational" LoopRepeat="25">
          <Name>DRUG IDENTIFICATION</Name>
          <StartingSegment SegmentId="LIN" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="CTP" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
        </Loop>
        <Loop LoopId="2420A" Usage="Situational" LoopRepeat="1">
          <Name>RENDERING PROVIDER NAME</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="82"/>
          </StartingSegment>
          <Segment SegmentId="PRV" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
        </Loop>
        <Loop LoopId="2420B" Usage="Situational" LoopRepeat="1">
          <Name>PURCHASED SERVICE PROVIDER</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="QB"/>
          </StartingSegment>
          <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
        </Loop>
        <Loop LoopId="2420C" Usage="Situational" LoopRepeat="1">
          <Name>SERVICE FACILITY LOCATION</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="77"/>
            <EntityIdentifier Code="FA"/>
            <EntityIdentifier Code="LI"/>
            <EntityIdentifier Code="TL"/>
          </StartingSegment>
          <Segment SegmentId="N3" Usage="Required" Repeat="1"/>
          <Segment SegmentId="N4" Usage="Required" Repeat="1"/>
          <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
        </Loop>
        <Loop LoopId="2420D" Usage="Situational" LoopRepeat="1">
          <Name>SUPERVISING PROVIDER NAME</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="DQ"/>
          </StartingSegment>
          <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
        </Loop>
        <Loop LoopId="2420E" Usage="Situational" LoopRepeat="1">
          <Name>ORDERING PROVIDER NAME</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="DK"/>
          </StartingSegment>
          <Segment SegmentId="N3" Usage="Required" Repeat="1"/>
          <Segment SegmentId="N4" Usage="Required" Repeat="1"/>
          <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
          <Segment SegmentId="PER" Usage="Situational" Repeat="5"/>
        </Loop>
        <Loop LoopId="2420F" Usage="Situational" LoopRepeat="1">
          <Name>REFERRING PROVIDER NAME</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="DN"/>
            <EntityIdentifier Code="P3"/>
          </StartingSegment>
          <Segment SegmentId="PRV" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
        </Loop>
        <Loop LoopId="2420G" Usage="Situational" LoopRepeat="1">
          <Name>OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER</Name>
          <StartingSegment SegmentId="NM1" Usage="Situational" Repeat="1">
            <EntityIdentifier Code="PR"/>
          </StartingSegment>
          <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
        </Loop>
        <Loop LoopId="2430" Usage="Situational" LoopRepeat="25">
          <Name>Service Line Adjudication Information</Name>
          <StartingSegment SegmentId="SVD" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="CAS" Usage="Situational" Repeat="99"/>
          <Segment SegmentId="DTP" Usage="Situational" Repeat="1"/>
        </Loop>
        <Loop LoopId="2440" Usage="Situational" LoopRepeat="5">
          <Name>FORM IDENTIFICATION CODE</Name>
          <StartingSegment SegmentId="LQ" Usage="Situational" Repeat="1"/>
          <Segment SegmentId="FRM" Usage="Required" Repeat="99"/>
        </Loop>
      </Loop>
    </Loop>
  </HierarchicalLoop>
</TransactionSpecification>